April 20, 2011 Jeanne Rust

Eating Disorders May Be Misdiagnosed

A very thin woman walked into her physician's office for an exam. She had not seen her doctor in years, but felt so chronically fatigued and ill that she knew she needed help. During the interview, she disclosed that she had not had a menstrual period in over seven years. The doctor's response was, "What's wrong? Did you have a hysterectomy?"

The physician failed to recognize that his patient was suffering from an eating disorder simply because he was unfamiliar with symptoms of the disease. Misdiagnosis of eating disorders is frighteningly common, and treatment may be delayed for years because the patient was advised to simply "eat more".

Physicians need to know that eating disorders have the highest mortality rate of any mental illness. 5 – 10% of anorexics die within 10 years, 18-20% die within 20 years, and only 30 – 40% ever fully recover. The mortality rate associated with anorexia nervosa is 12 times higher than the death rate from ALL causes for females ages 15 to 24. 20% of people suffering from anorexia will die prematurely of complications related to their eating disorders, including suicide and heart problems.

Complications from bulimia nervosa also to earlier death than the patient might otherwise experience. The death rate of people who are obese is unknown since death certificates normally list cause of death as heart disease or complications from diabetes.

Individuals with undiagnosed eating disorders often present with a variety of seemingly unrelated symptoms, including:

Physical Symptoms

  • low iron
  • menstrual disturbances or amenorrhea
  • gastrointestinal symptoms
  • Type 1 diabetes and poor treatment adherence
  • low body mass index (BMI) compared with age norms, or fluctuating weight

Psychological Symptoms

  • depression, mood swings, anxiety
  • substance abuse
  • sleep disturbance
  • lack of concentration
  • obsessive symptoms, particularly related to food and weight
  • self-harming behaviors

Social Difficulties

  • change in social pattern
  • school or work problems
  • problems in the family and/or other relationships
  • involvement with the justice system

When an eating disorder is suspected, the doctor can gently probe for additional information with questions such as:

  • "Many people have concerns about food. Please tell me about your eating habits. Do you worry about your eating, or do you think that others do?"
  • "Some people have concerns about their weight. Please tell me how you feel about your body and weight."
  • "Some people have trouble with eating to the point of discomfort. Please tell me when this has been a problem for you."

If the patient reveals concerns about food, eating habits, or weight, it's important to ask for additional details in an empathetic and non-judgmental manner.
It is crucial that the physician determine whether the patient needs additional care from an outpatient psychotherapist who specializes in eating disorders, or from an inpatient treatment facility. Hospitalization is a last resort and should only be considered when an individual is severely medically compromised or at risk of serious self-harm.

Eating Disorder Symptoms in Adults

  • Heart rate < 40 bpm
  • Blood pressure <90/60mm Hg
  • Symptomatic hypoglycemia
  • Potassium <3 mmol per liter
  • Temperature < 36.1 c (97.0 F)
  • Dehydration
  • Cardiovascular abnormalities other than bradycardia
  • Weight <75 per cent of the expected weight
  • Rapid weight loss within a short period of time
  • Lack of improvement or rapid worsening despite outpatient treatment

Eating Disorder Symptoms in Children and Adolescents

  • Heart rate <50 bpm
  • Orthostatic blood pressure resulting in increase in heart rate of >20 bpm, or resulting in a drop in blood pressure of >10 to 20 mm Hg
  • Blood pressure <80/50 mm Hg
  • Hypokalemia or hypophosphatemia
  • Rapid weight loss within a short period of time
  • Symptomatic hypoglycemia or fasting glucose <3.0 mmol per liter
  • Lack of improvement or worsening despite outpatient treatment

Psychological Indications

  • Poor motivation or insight (inability to recognize the seriousness of severe weight loss) or lack of cooperation with outpatient treatment
  • Inability to eat independently or need for nasogastric feeding
  • Suicidal plan or marked suicidal ideation
  • Severe coexisting psychiatric disease
  • Anti-therapeutic family environment, especially if abuse is present

Educating physicians about eating disorders and how to recognize them is of vital importance as both the prevalence and the severity of eating disorders continues to increase.